Membership Sponsor Form

Membership Sponsor Form

NOTE: Sponsorship forms should be completed only by Active Rhinoplasty Society Members who know the applicant's work, character, and professional reputation, and can support the application for Membership

I wish to sponsor the following applicant for membership in The Rhinoplasty Society:

Applicant's Name:

Address:

City:

State:

Zip:

  1. How long have you know the applicant personally?
    years
  2. How long have you know the applicant professionally?
    years
  3. Does this applicant have an established practice as a surgeon with primary responsibility?
    YesNo
  4. What portion of this applicant’s practice is functional or aesthetic rhinoplasty?
    %
  5. Have you assisted the applicant or has the applicant assisted you in surgery?
    YesNo
  6. Do you know of any past, present, or pending adverse action taken which could limit or restrict the applicant’s medical license or hospital staff privileges at any hospital? (Please provide appropriate documentation for a “yes” response. Acceptable formats include PDF, DOC or DOCX)
    YesNo
  7. Attach Documentation for yes response

  8. What is your opinion regarding the applicant’s professional and ethical standing among physicians in his/her community?
    ExcellentGoodSatisfactoryNot SatisfactoryUnknown
  9. Do you recommend this applicant for membership in The Rhinoplasty Society?
    YesNo
  10. Would you have this applicant cover your practice in your absence?
    YesNo

Required Supporting Comments

Would you have this applicant cover your practice in your absence?

Sponsor:

Address:

City:

State:

Zip:

Telephone:

Email Address:

I verify that the information above is accurate and that I wish to sponsor the above named individual for membership in The Rhinoplasty Society